Patient Resources: Billing, Insurance, Medical Records (2024)

Table of Contents
Health care how you want it Get started with My Marshfield Clinic Consent Forms: General Consent to Treatment Spanish: Consentimiento – Tratamiento a Menores – Limitado (A Ser Utilizado Una Sola Vez) Consent - Treatment of Minors - (One Time Use)​​​​ Spanish: Consentimiento – Tratamiento a Menores – Limitado (A Ser Utilizado Una Sola Vez) Consent - Treatment of Adult Ward in Legal Guardian Absence Spanish: Consentimiento – Tratamientos Para un Protegido Adulto en la Ausencia del Tutor Legal ​​Consent - Treatment of Minors in Parent/Legal Guardian Absence Spanish: Consentimiento – Tratamiento de Menores en Ausencia del Padre/Tutor Legal Consent Revocation - Treatment of Minor/Adult Ward i​n Parent/Legal Guardian Absence​ Spanish: Revocación del Consentimiento – Tratamiento de Menores/Adultos Bajo Tutela en Ausencia del Padre/Tutor Legal Voluntary COVID-19 Vaccination of Minors in Parent/Legal Guardian Absence​ Release of Information Forms Release of Information ​​Authorization ​​Spanish: Descargo de Autorización de Información Sharing of Information Authorization Spanish: Autorización Para Compartir Información Hmong: Daim Ntawv Tso Cai Saib Cov ntaub Ntawv Release of Information Authorization Occupational Medicine Release of Information Revocation Notice​ Spanish: Aviso de Revocación de la Divulgación de Información HIPAA-R​elated Forms Accounting of Disclosures Request Form Spanish: Solicitud de Divulgación de Información – Registro de Divulgaciones Amendment/Correction of Health Information Request Form Spanish: Solicitud de Di​vulgación de Información – Enmienda/Corrección de la Información de Salud Restriction of Information Request Form Spanish: Solicitud de Divulgación de Información – Restricciones Por Paciente Mis​cellaneous Forms Financial Assistance Application Checklist Spanish: Lista de Verificación Aplicación Para Solicitud de Asistencia Financiera​ Hmong: Daim Ntaw​v Sau Qhia Thov Nyiaj Pab​​ Marshfield Medical Center-Beaver Dam Chiropractic Clinic New Patient Registration Form​​​ Patient Financial Services Patient Assistance Center Insurance Eligibility Helpline​ Release of Information ​​Authorization ​​Spanish: Descargo de Autorización de Información Sharing of Information Authorization Spanish: Autorización Para Compartir Información Hmong: Daim Ntawv Tso Cai Saib Cov ntaub Ntawv General Consent to Treatment ​Consent - Treatment of Minors - Limited (One Time Use)​​​​ Spanish: Consentimiento – Tratamiento a Menores – Limitado (A Ser Utilizado Una Sola Vez) Hmong:Tso Cai Kho Rau Cov Menyuam Uas Tsis Tau Muaj Hnub Nyoog (Siv Ib Zaug Xwb) Consent - Treatment of Adult Ward in Legal Guardian Absence​ Spanish: Consentimiento – Tratamientos Para un Protegido Adulto en la Ausencia del Tutor Legal Hmong: Daim Ntawv Tso Cai – Kev Kho Ib Tug Neeg Laus Uas Tsis Txawj thaum Tsis Muaj Tus Neeg Saib Xyuas Nyob Rau Ntawd ​​Consent - Treatment of Minors in Parent/Legal Guardian Absence Spanish: Consentimiento – Tratamiento de Menores en Ausencia del Padre/Tutor Legal Hmong: Daim Ntawv Tso Cai – Kho Cov Menyuam Uas Tsis Tau Nto Hnub Nyoog Thaum Niam Txiv/Niam Qhuav Txiv Qhuav Uas Tau Kev Tso Cai Sawv Cev Raws Txoj Cai Tsis Nyob Rau Ntawd​ Release of Information Request -​​ Amendment/Correction of ​​​Health Information Spanish: Solicitud de Di​vulgación de Información – Enmienda/Corrección de la Información de Salud Release of Information Request​ - Restrictions by Patient Spanish: Solicitud de Divulgación de Información – Restricciones Por Paciente Release of Information Request - Accounting of ​Disclosures Spanish: Solicitud de Divulgación de Información – Registro de Divulgaciones Release of Information Revocation Notice​​​ Spanish: Aviso de Revocación de la Divulgación de Información Consent Revocation - Treatment of Minor/Adult Ward in Parent/Legal Guardian Absence​ Spanish: Revocación del Consentimiento – Tratamiento de Menores/Adultos Bajo Tutela en Ausencia del Padre/Tutor Legal Financial Assistance Application Checklist Spanish: Lista de Verificación Aplicación Para Solicitud de Asistencia Financiera​ Hmong: Daim Ntaw​v Sau Qhia Thov Nyiaj Pab​​ Voluntary COVID-19 Vaccination of Minors in Parent/Legal Guardian Absence​​ Marshfield Medical Center-Beaver Dam Chiropractic Clinic New Patient Registration Form​​​ Release of Information Authorization Occupational Medicine ​​ References

Patient Resources: Billing, Insurance, Medical Records (1)​​

Health care how you want it

Manage health care on your time. My Marshfield Clinic is your go-to place for organizing health care available via our website or through the mobile app. For most patients, sign-up only takes minutes.


Get started with My Marshfield Clinic

Sign in Create an account

Contact theMarshfield Clinic Helpline at: 877-349-9449.​​​​​​​​​​​​​

Make a payment now


Common billing questions​​

Find information regardingyourbills, insurance and account changes.

Frequently asked questions aboutprovider-basedbilling

Health care services provided in the medical officesat certain Marshfield Clinic Health System locations will be considered hospital outpatientservices and provider-based. This means these services will be billed as hospital outpatient care.

Learn more about provider-based billing >

Estimate the cost of your care (​Fee Estimates)
Understand the costs of your next visit.

Patient Assistan​ce Center​​​​​​​​​​​​​​​​​​​​​​​
Make informed decisions about financing health care.

Financial Assistance​
Apply for free or discounted rates at Marshfield Clinic.​​​​​​​​​​

Accepted insurance plans

Patient guide to insurance

Common coverage questions

Understanding payments and copayments

The Health Insurance Marketplace​

Medicare patient information​​​​​​​​​​​

Spanish: Política de Ayuda Financiera​

Hmong:​ Daim ntawv thov nyiaj txoj cai​​​​​​​​​​​​​​​​

Consent Forms:

  • General Consent to Treatment

    Spanish: Consentimiento – Tratamiento a Menores – Limitado (A Ser Utilizado Una Sola Vez)

  • Consent - Treatment of Minors - (One Time Use)​​​​

    Spanish: Consentimiento – Tratamiento a Menores – Limitado (A Ser Utilizado Una Sola Vez)

  • Consent - Treatment of Adult Ward in Legal Guardian Absence

    Spanish: Consentimiento – Tratamientos Para un Protegido Adulto en la Ausencia del Tutor Legal

  • ​​Consent - Treatment of Minors in Parent/Legal Guardian Absence

    Spanish: Consentimiento – Tratamiento de Menores en Ausencia del Padre/Tutor Legal

  • Consent Revocation - Treatment of Minor/Adult Ward i​n Parent/Legal Guardian Absence​

    Spanish: Revocación del Consentimiento – Tratamiento de Menores/Adultos Bajo Tutela en Ausencia del Padre/Tutor Legal

  • Voluntary COVID-19 Vaccination of Minors in Parent/Legal Guardian Absence​

    Release of Information Forms

  • Release of Information ​​Authorization

    ​​Spanish: Descargo de Autorización de Información

  • Sharing of Information Authorization

    Spanish: Autorización Para Compartir Información

    Hmong: Daim Ntawv Tso Cai Saib Cov ntaub Ntawv

  • Release of Information Authorization Occupational Medicine

  • Release of Information Revocation Notice​

    Spanish: Aviso de Revocación de la Divulgación de Información

    HIPAA-R​elated Forms

  • Accounting of Disclosures Request Form

    Spanish: Solicitud de Divulgación de Información – Registro de Divulgaciones

  • Amendment/Correction of Health Information Request Form

    Spanish: Solicitud de Di​vulgación de Información – Enmienda/Corrección de la Información de Salud

  • Restriction of Information Request Form

    Spanish: Solicitud de Divulgación de Información – Restricciones Por Paciente

​​

Advance directive form (PDF​​)

Advance directive appointment prep (PDF)

Being a health care agent (PDF)


Learn more about advance care planning and how Marshfield Clinic Health System can help:​

Viewadvance directive​ information >​​​​

Wambi - Send a heartfelt thank you

Shining Star – Special recognition with a gift

DAISY Award – Honor an extraordinary nurse

Gratitude is a gift that benefits the giver and the receiver. Choose from three great options to recognize and celebrate exceptional care at Marshfield Clinic Health System.

Share your gratitude now >​​​​​​​​​

Send us a message

Patient Financial Services

Make a payment, payment questions, ormodify apayment plan. Get help withonline bill pay.

1-888-258-9775Ext. 9-0700

Patient Assistance Center

Getcost-of-care estimates orinquire about financial assistance

1-800-782-8581Ext.9-4475​​

Insurance Eligibility Helpline

Update insurance information, insuranceand service coverage, plus eligibilityand referralassistance.

1-800-782-8581Ext. 7-5559​

​​​​​​


  • Release of Information ​​Authorization

    ​​Spanish: Descargo de Autorización de Información

  • Sharing of Information Authorization

    Spanish: Autorización Para Compartir Información

    Hmong: Daim Ntawv Tso Cai Saib Cov ntaub Ntawv

  • General Consent to Treatment

  • Consent - Treatment of Minors - Limited (One Time Use)​​​​

    Spanish: Consentimiento – Tratamiento a Menores – Limitado (A Ser Utilizado Una Sola Vez)

    Hmong:Tso Cai Kho Rau Cov Menyuam Uas Tsis Tau Muaj Hnub Nyoog (Siv Ib Zaug Xwb)

  • Consent - Treatment of Adult Ward in Legal Guardian Absence​

    Spanish: Consentimiento – Tratamientos Para un Protegido Adulto en la Ausencia del Tutor Legal

    Hmong: Daim Ntawv Tso Cai – Kev Kho Ib Tug Neeg Laus Uas Tsis Txawj thaum Tsis Muaj Tus Neeg Saib Xyuas Nyob Rau Ntawd

  • ​​Consent - Treatment of Minors in Parent/Legal Guardian Absence

    Spanish: Consentimiento – Tratamiento de Menores en Ausencia del Padre/Tutor Legal

    Hmong: Daim Ntawv Tso Cai – Kho Cov Menyuam Uas Tsis Tau Nto Hnub Nyoog Thaum Niam Txiv/Niam Qhuav Txiv Qhuav Uas Tau Kev Tso Cai Sawv Cev Raws Txoj Cai Tsis Nyob Rau Ntawd​

  • Release of Information Request -​​ Amendment/Correction of ​​​Health Information

    Spanish: Solicitud de Di​vulgación de Información – Enmienda/Corrección de la Información de Salud

  • Release of Information Request​ - Restrictions by Patient

    Spanish: Solicitud de Divulgación de Información – Restricciones Por Paciente

  • Release of Information Request - Accounting of ​Disclosures

    Spanish: Solicitud de Divulgación de Información – Registro de Divulgaciones

  • Release of Information Revocation Notice​​​

    Spanish: Aviso de Revocación de la Divulgación de Información

  • Consent Revocation - Treatment of Minor/Adult Ward in Parent/Legal Guardian Absence​

    Spanish: Revocación del Consentimiento – Tratamiento de Menores/Adultos Bajo Tutela en Ausencia del Padre/Tutor Legal

  • Financial Assistance Application Checklist

    Spanish: Lista de Verificación Aplicación Para Solicitud de Asistencia Financiera​

    Hmong: Daim Ntaw​v Sau Qhia Thov Nyiaj Pab​​

Patient Resources: Billing, Insurance, Medical Records (2024)

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